Analysis BMJ Glob Health: first published as 10.1136/bmjgh-2017-000656 on 20 January 2018. Downloaded from Strengthening global health security by embedding the International Health Regulations requirements into national health systems

Hans Kluge,1 Jose Maria Martín-Moreno,2 Nedret Emiroglu,3 Guenael Rodier,4 Edward Kelley,5 Melitta Vujnovic,6 Govin Permanand7

To cite: Kluge H, Abstract As the leading global organisation with Martín-Moreno JM, Emiroglu N, The International Health Regulations (IHR) 2005, as the responsibility for health governance, WHO et al. Strengthening global overarching instrument for global health security, are has bore the brunt of the criticism.5–7 health security by embedding designed to prevent and cope with major international the International Health Depending on the crisis, accusations have public health threats. But poor implementation in countries Regulations requirements hampers their effectiveness. In the wake of a number of ranged from responding too slowly or in ad into national health hoc fashion, to over-reacting and fear-mon- systems. BMJ Glob Health major international health crises, such as the 2014 Ebola 2018;3:e000656. doi:10.1136/ and 2016 Zika outbreaks, and the findings of a number gering, as well as not learning lessons and bmjgh-2017-000656 of high-level assessments of the global response to these not making necessary structural and organ- crises, it has become clear that there is a need for more isational reforms. Proposals for taking the Handling editor Seye Abimbola joined-up thinking between health system strengthening health security agenda forward have thus activities and health security efforts for prevention, alert included reaffirming and strengthening Received 23 November 2017 and response. WHO is working directly with its Member Revised 18 December 2017 States to promote this approach, more specifically around WHO’s central role and the need to better Accepted 19 December 2017 how to better embed the IHR (2005) core capacities resource the organisation, to removing into the main health system functions. This paper looks emergency response from WHO’s purview, at how and where the intersections between the IHR and even setting up a new body entirely.8 9 and the health system can be best leveraged towards Against the backdrop of such debate, WHO 1Health Systems and developing greater health system resilience. This merging continues to implement a wider reform of approaches is a key component in pursuit of Universal http://gh.bmj.com/ Public Health, World Health process which, since Ebola, includes emer- Organization Regional Office for Health Coverage and strengthened global health security as two mutually reinforcing agendas. gency capacities and work in promoting Europe, Copenhagen, Denmark i 2Preventive Medicine and Public global health security . Health and University Clinical Central to these discussions are the Interna- Hospital INCLIVA, University of Background tional Health Regulations (IHR), which have Valencia, Valencia, Spain In today's increasingly interconnected and

3 been at the heart of the global health security on September 27, 2021 by guest. Protected copyright. Communicable Diseases and Health Security, World Health interdependent world, where people, goods agenda since 1969 (preceded by the Interna- Organization Regional Office for and services move easily across borders, it tional Sanitary Regulations from 1951). The Europe, Copenhagen, Denmark is more important than ever to ensure that IHR aim to prevent, protect against, control 4Country Health Emergency countries are able to respond in timely and and provide a response to public health Preparedness and IHR, World effective fashion to contain, and indeed Health Organization, Geneva, threats through improved surveillance, prevent, threats to public health.1–3 Recent Switzerland reporting and international cooperation, and 5 global health crises, including H1N1 influ- Service Delivery and Safety, to do so in ways which avoid unnecessary inter- World Health Organization, enza (2009), Ebola (2014) and Zika (2016) ference with international traffic and trade.10 Geneva, Switzerland have resulted in pointed criticisms of the 6 World Health Organisation international health community’s ability to Today, the IHR (2005) represent a binding Representative, Moscow, deal with such threats. But crises also offer instrument on the 196 ‘States Parties’, on Russian Federation whom rest responsibility for acquiring the 7Health Systems and opportunities for learning and improvement. Public Health, World Health An important result of such criticism has core capacity for surveillance and response Organization Regional Office for been an incremental strengthening of inter- required under the IHR (2005) and for overall Europe, Copenhagen, Denmark national resolve and know-how to promote adherence to the Regulations, although their Correspondence to and improve global health security (covering Dr Govin Permanand; both individual and collective health security i See http://www.who.int/about/who_reform/en/ for 4 permanandg@​ ​who.int​ at global/international level ). more information.

Kluge H, et al. BMJ Glob Health 2018;3:e000656. doi:10.1136/bmjgh-2017-000656 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2017-000656 on 20 January 2018. Downloaded from

to national health systems, rather than seen as a top-down Key questions set of externally imposed stipulations. What is already known about this topic? In making the case for better embedding the IHR into national health systems in pursuit of Universal Health ►► There is little known and very little, if any, published on this topic. ►► Despite being legally binding on all International Health Coverage (UHC), this paper outlines the need for more Regulations (IHR) States Parties (which include all 194 WHO joined-up thinking between the IHR core capacities and Member States), the IHR (2005) core capacity requirements have health system functions. It provides a brief outline of the been poorly implemented in most countries, particularly in those IHR before focusing on a number of important intersec- that are resource-poor and vulnerable. tions with health systems and showing where they can be ►► This deficit in awareness and implementation, highlighted in the built on. In closing, we touch on actions that WHO is aftermath of the 2014 Ebola and 2016 Zika epidemics, has only taking to increase its effectiveness in this area and stress recently been brought to the attention of the global public health the importance of strong health systems for delivering community with the understanding that IHR (2005) core capacities IHR commitments. The aim is to identify a number of are an integral part of the essential public health functions and key issues in order to prompt discussion about health need to be embedded into the health system functions. systems and global health security in general, as well as What are the new findings? WHO’s role and the IHR. ►► That health system strengthening and health security efforts for prevention, alert and response need to be pursued in tandem, as part of the same mutually reinforcing approach to developing The International Health Regulations: working for resilient health systems, is a new understanding. global health security ►► There is now a demonstrated need to embed the IHR (2005) Following the Severe Acute Respiratory Syndrome crisis core capacities into health systems, across the six health system of 2003, the international community agreed to improve functions, where the leadership and governance function is probably the most important to improving IHR implementation and the detection, reporting and response to potential public pursuing Universal Health Coverage (UHC). health emergencies worldwide. This required re-evalu- ►► UHC supports health security (eg, preventing outbreaks through ating the existing IHR (1969), which was a framework for high immunisation coverage, providing early alert by rapid access reporting only three infectious diseases: cholera, plague of all patients to healthcare, better response thanks to reliable and yellow fever (smallpox was removed in 1981 following infrastructure and healthcare workforce for case management, etc), its official eradication in 1980). The result was a new while health security investment supports UHC by avoiding health articulation of the IHR in 2005 that widened the scope crises that prevent patients accessing healthcare (eg, a health of coverage to include all events (including chemical and workforce diverted from regular care to focus on crisis response, or nuclear hazards) that could lead to Public Health Emer- is itself victim of the crisis as seen during Severe Acute Respiratory gencies of International Concern (PHEIC). The revised Syndrome, influenza pandemics, Ebola, etc; or patients’ fear of IHR (2005) came into force in 2007. contamination sees them avoid regular care seeking). In 2009, in the aftermath of the H1N1 influenza ►► Understanding this mutual reinforcement and the urgent need for http://gh.bmj.com/ joint work and synergy between health system strengthening and pandemic, WHO’s Executive Board convened an inde- 12 health security efforts is a new concept. pendent review of the effectiveness of the IHR (2005). The review highlighted a number of positives but Recommendations for policy concluded that more was required for the world to ►► Close coordination between the health system and health security respond adequately to sustained public health emer- is a new approach which is gaining momentum as major donors gencies, and delivered a series of recommendations (as well as the G7 and G20) want to see systematic coordination on September 27, 2021 by guest. Protected copyright. including lessons for future PHEICs. The 2014 Ebola between UHC and global health security. outbreak again put the IHR (2005) to the test. And ►► Things are already changing, for instance, through the Joint External Evaluations (JEE) for country health emergency preparedness and the subsequent assessments, including WHO’s own commis- 8 subsequently developed national action plans, which embed health sioned review by the Ebola Interim Assessment Panel, security functions within the national health system strategy and identified a number of failures—most notably that WHO budget. reacted slowly with poor communication, also indicating ►► In future, it is expected that the bridge between health systems that the organisation and IHR State Parties did not act on and global health security will become stronger given their shared the H1N1 review recommendations. The 2016 Zika virus objective of creating resilient health systems. outbreak once again put the IHR (2005) under scrutiny, highlighting the importance of efficient surveillance. ‘enforceability’ has long been seen as a concern.11 WHO Despite such ‘tests’—or precisely because of them and works directly with countries to make the IHR (2005) the improvement cycle they precipitate—the IHR (2005) obligations easier to implement and maintain. More- remain the pre-eminent instrument to address interna- over, a concerted effort is underway to ensure that the tional public health threats and a fundamental compo- IHR requirements are an integral part of essential public nent of global health security. health operations and to better embed them into WHO’s The IHR (2005) require a minimum set of ‘core capac- health systems strengthening work. This is to ensure that ities’ from its signatories. Laid out in their Annex 1, these the IHR (2005) core capacity requirements are integral include for the health system:

2 Kluge H, et al. BMJ Glob Health 2018;3:e000656. doi:10.1136/bmjgh-2017-000656 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2017-000656 on 20 January 2018. Downloaded from

►► the ability to detect and assess events (ensure that sur- reviews. The JEE and the other assessment instruments veillance systems and laboratories can detect poten- help assess gaps to develop a national action plan to tial threats, and understand the nature and potential strengthen country IHR capacity, including through severity and impact of the event in order to be able to multisectoral actioniii. make decisions in public health emergencies); Much of the data and feedback can also be related to ►► notify and report events (report specific diseases, plus how well the health system itself is functioning, as the any potential public health emergencies, to WHO IHR (2005) ‘address a subset of health systems strength- through a network of ‘National IHR Focal Points’); ening and coordination challenges’.14 A country’s ability ►► verify and respond (countries are expected to be able to detect, report and respond to health threats requires to implement preliminary control measures immedi- strong relationships between, for example, clinical labo- ately and respond appropriately to public health risks ratories and health information systems and medical tech- and emergencies).10 nologies, and between numbers of emergency personnel The IHR (2005) also require some core capacity for and training of the public health workforce. Moreover, designated airports, ports and ground crossings—‘Points emergency responses to health threats involve coordi- of Entry’—at all times, as well as responding to PHEICs, nation, financing, incident management systems, public in order to limit the international spread of public health awareness and community engagement, underpinned by risks and to prevent unwarranted travel and trade restric- strong government commitment and resources.15 These tions. There are further expectations around countries’ are all system issues, and are reflected in the WHO health capacity for coordination (multisectoral action, eg, systems frameworkiv, which comprises six independent between health, transport, food, agriculture, the environ- but inter-related building blocks working in tandem: ment, etc) and ability to mutually support each other in (1) service delivery, (2) health workforce, (3) health the event of a public health emergency. information systems, (4) medical products, vaccines and Once an event is reported, WHO reviews the situation health technologies, (5) health financing and (6) leader- declaring the event a PHEIC if it is thought to constitute ship and governance.16 A recent systematic review of the a public health risk to other countries through the inter- building blocks’ relevance to the Ebola outbreak under- national spread of disease, and if it potentially requires lines their importance in practice and as an evaluative a coordinated international response. To date, despite framework.17 increasing numbers of potential events being reported, While all of these components are necessary for organ- and hundreds of updates and announcements posted on ising a system-wide response, this paper focuses primarily the IHR event information site for National IHR Focal on two areas at the backbone of any response to a public Points, WHO has declared just four PHEICs: influenza A health emergency, and where the IHR-health system (H1N1) pandemic (2009), international spread of Polio intersections can be particularly strengthened and better (2014), Ebola epidemic in West Africa (2014) and cluster institutionalised in countries: leadership/governance of microcephaly and Guillain-Barré syndrome in the and health information systems. These blocks are broader http://gh.bmj.com/ context of Zika epidemics (2016). functional domains, requiring more cross-cutting policy responses and long-term strategic planning.

Intersections with health systems Leadership and governance WHO supports assessments of countries’ IHR (2005) Of all of the health system building blocks, leadership and ‘core capacities’. To date, these have been self-reported governance is probably the most important in improving and involve States Parties returning annually a completed IHR implementation and in countering outbreaks in on September 27, 2021 by guest. Protected copyright. questionnaire to WHO. Implementation and reporting general. It underpins the other health system compo- 11 13 has not been consistent across countries, and the infor- nents and constitutes the cornerstone of any effort to mation does not necessarily indicate how the IHR (2005) strengthen health security. This is true at both national capacity requirements are actually implemented in the and global level. ii country . To improve the quality of reporting, countries At national level, where compliance with IHR (2005) have been recommended to move from exclusive self-eval- remains patchy despite a WHO-issued series of guidance uation to approaches that combine self-evaluation, peer for implementation in national legislationv, a stronger review and voluntary external evaluations involving a legal basis to overcome the lack of a formal enforce- combination of domestic and independent experts. This ment mechanism and to ensure coordinated and rapid has been addressed by the newly proposed IHR Moni- action through the health system could help to address toring and Evaluation Framework which includes, in addition to the self-evaluation, voluntary Joint External Evaluation (JEE), simulation exercises and after-action iii See http://apps.who.int/iris/handle/10665/204368. iv WHO defines a health system as consisting of all organisations, people and actions whose primary intent is to promote, restore or main- ii The Commission on Creating a Global Health Risk Framework for the tain health. Its goals are improved health and health equity towards Future (GHRF) noted in its report that only a third of countries had so Universal Health Coverage (UHC). far complied with the IHR (2005) requirements. v See http://www.who.int/ihr/legal_issues/legislation/en/.

Kluge H, et al. BMJ Glob Health 2018;3:e000656. doi:10.1136/bmjgh-2017-000656 3 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2017-000656 on 20 January 2018. Downloaded from some of the implementation gaps and failings already as animal health, transport, education, finance, civil identified. For instance, the USA employs a public health defence and security. Towards such an objective, Article legal preparedness (PHLP) framework, which represents 44 of the IHR (2005) on ‘collaboration and assistance’, a legal imperative for multisectoral action in emergen- requires WHO, to the extent possible, to work with other cies.18 While the US framework was borne of the need to international bodies and networks, and this could be serve a federal structure, there is a need for something further leveraged in a more proactive manner. similar in countries in order to formally mandate obliga- Finally, messaging is crucial. In a global health climate tory multisectoral responses in support of health system characterised by the need to demonstrate outcomes, it is emergency preparedness and the IHR (2005). And difficult to ‘sell’ prevention and preparedness. Govern- while this cannot necessarily eliminate the potential for ments should acknowledge that health security has a domestic political factors to impede IHR (2005) compli- cost with no immediate apparent outcome, but that such ance— as was the case with both the H1N1 pandemic and investment is irreplaceable in the face of an imminent Ebola outbreak—such a meso-level bottom-up approach health emergency. When the health system is capable of can help to ensure an adequate response and make the preventing, detecting or effectively addressing a public case for greater compliance. This is in line with calls from health threat, the greatest beneficiary is society at large. civil society for a ‘socialisation’ of the IHR (2005),19 the At the same time, many actors of the national economy need for strong intervention at and with community (eg, transport, tourism and trade) and the private sector level20 and the need to confer national ownership to also benefit. Thus, the messaging around investing in countries. A stronger implementation of the IHR (2005), health security needs to be less on the tools and proce- both in terms of its embedding into the fabric of health dures and more on the ‘destination’, for example, a safer systems and into national law, potentially supported via world such that public health emergencies do not spread an external funding source,21 could facilitate improved globally and have limited if any impact on international and timely detection and response to health threats, and travel, trade and the economy. governance more widely. Regarding the global level, WHO’s strengthening Health information systems of the IHR (2005) is not just normative but construc- Surveillance and monitoring is another central pillar of tive. In a global health environment characterised by the IHR (2005). Yet many countries continue to lack the an increasing number of actors and agencies, WHO is required capabilities.13 25 From a health systems perspec- the de facto steward, facilitating action and collabo- tive, this is a concern but perhaps not surprising; a recent ration within the global health system at large.22 This review of a number of leading health system frameworks involves priority setting at global level, and ensuring that found that surveillance capacity was in general insuffi- IHR (2005) and health system strengthening activities ciently integrated, and in some cases even non-existent as are part of wider international frameworks and direc- a dedicated function (WHO, unpublished report, 2015). tions, such as the move towards UHC and the Sustain- Where surveillance was included, it was indicator-based, http://gh.bmj.com/ able Development Agenda 2030. Strong health systems, in turn highlighting the need for more event-based resilient to health crises, and with robust emergency poli- surveillance for quicker risk and event detection as called cies are central to UHC, and research has highlighted for under the IHR (2005). that a resilient health system is indeed one that is moving National health information systems need to have towards UHC.23 24 WHO can help to ensure that coun- the ability to detect, verify and track events as soon as tries work towards meeting the Sustainable Develop- possible, and to ensure the flow of health data among on September 27, 2021 by guest. Protected copyright. ment Goals in line with global emergency preparedness a variety of national and international stakeholders activities (eg, in health financing and human resources (including WHO). Moreover, they need to be able for health). Collaboration with relevant international to rapidly transform such data into information for initiatives, such as the Global Health Security Agendavi, real-time decision-making. All of this implies a good support global health security as an international priority integration of data sources and systems, involving and global public good requiring full implementation of surveillance, clinical and laboratory services, alert func- the IHR (2005). tions, evidence synthesis and communication activities, Additionally, there are long-standing calls for WHO to census results, observational data and health system work more closely with non-state actors such as the private resources data. Continuing improvement of incident sector and civil societyvii. Such engagement is necessary to management systems requires the integration and institutionalise the IHR (2005) requirements and build standardisation of information and reporting require- up health systems emergency response capacity.20 21 Simi- ments so that they are in place during emergency larly, WHO needs to continue developing relationships responses. Most countries already have some type of with partners and donors in other relevant sectors such public health surveillance system that measures disease burden and mortality/morbidity trends in order to vi See https://ghsagenda.org/. guide programmes and resources, along with an early vii WHO is developing protocols in this area (http://www.who.int/ warning and response system for public health threats. about/collaborations/non-state-actors/en/). Integrating the IHR (2005) requirements into such

4 Kluge H, et al. BMJ Glob Health 2018;3:e000656. doi:10.1136/bmjgh-2017-000656 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2017-000656 on 20 January 2018. Downloaded from systems, and creating or strengthening them where they need to be in place; moreover, stockpiles need to be real are weak or non-existent, is a necessity. rather than simply pledged. Close relations with the But the IHR (2005) also have more specific surveillance private sector to help with drug development and vaccine requirements, such those as relating to ‘Points of Entry’. delivery in emergency situations are also required. In these jurisdictions, for example, customs, immigra- Another crucial issue for emergency preparedness and tion, shipping and conveyance authorities, etc, collecting response is human resources for health—in terms of public health data is rarely seen as a priority. Addressing numbers and availability, relevant expertise and training this is complex. It would require changing protocols and deployment. For IHR (2005) purposes, there is a to ensure that more and relevant data are collected raft of profiles required from the health workforce. This by such systems and services on an ongoing basis, as includes epidemiologists, clinicians, public health special- well as training officials and including public health/ ists, laboratory personnel, health information experts and medical personnel in such settings. This is equally the biostatisticians, risk communication professionals, sociol- case for veterinary public health and agriculture as per ogists and anthropologists, as well as doctors, nurses and the IHR (2005). Given the potential threats stemming veterinarians. Close collaboration with the health system from the movement of animals and livestock, and food can help to understand the optimal size, skill-mix and production and distribution, national health information distribution of the health workforce required, and can systems need to be able to ‘speak to’ and have interop- help in the design of appropriate training curricula. For erability with other sectors in terms of data exchange. instance, given the centrality of laboratory systems and This includes being able to capture local specificities and services to the IHR (2005), designing field epidemiology connect with affected communities and actors, an aspect and laboratory training programmes for staff are essen- of core capacity-building that is not explicitly covered tial, as is linking them to the health system. in the IHR (2005), and which was clearly lacking in the Finally, the importance of financing cannot be under- countries affected by the Ebola outbreak in West Africa.26 stated. In estimating the economic cost of the Ebola crisis on the economies of Guinea, Liberia and Sierra Mobilising other health system components for health Leone, the World Bank stresses how important invest- emergency preparedness and response ment in surveillance, detection and treatment capacity While leadership and health information systems require is (would have been).27 Countries need to invest in their long-term strategic thinking, the ability to quickly activate public health institutions and infrastructure, such as other health system building blocks are priorities both local laboratory and diagnostic services to identify the during emergencies and for securing the health system hazards and events which can lead to emergencies and itself. Fulfilment of the IHR (2005) requires contribu- potential PHEICs, as well as in specialist personnel and tions from all parts of the health system, encompassing supplies. Additionally, being able to mobilise health service delivery as well as human, financial and techno- system finances in an emergency situation is key. A health logical resources. financing component should therefore be a central http://gh.bmj.com/ With regard to services, how these are organised, element of a country’s IHR (2005) planning. managed and delivered is the most visible demonstration of the overall functioning and efficiency of the health system—especially during a crisis—and a core compo- Moving forward nent of the UHC agenda. The provision and mainte- In terms of more concrete actions, WHO is further nance of safe healthcare services (ie, with infection supporting IHR (2005) training and capacity develop- on September 27, 2021 by guest. Protected copyright. isolation procedures in place), together with other infec- ment in countries, promoting the effectiveness of surveil- tion control services that health professionals provide, is lance systems and supporting timely communication the frontline of outbreak response. With respect to the and information-sharing through the global network of IHR (2005), there is a need to improve the coordination national IHR focal points. To complement the voluntary of delivery systems for public health and clinical care JEE under the IHR Monitoring and Evaluation Frame- around emergencies— systems need to be flexible with work, WHO is promoting and supporting public health plans developed and functions articulated. Collaboration threat simulation exercises and after-action review, whose with other stakeholders, most notably the private sector results reflect the actual operational capacity of the alert for improved logistics in emergencies, is also needed. and response system. Local healthcare service providers and local commu- Additionally, the organisation is heeding calls for nities, along with civil society, must be involved as well. ‘housekeeping’.28 The implementation of the IHR (2005) Indeed, community awareness can boost surveillance,13 is often done in a vertical manner, outside the health and all can play a crucial role in the rapid delivery of key system strengthening effort at national level. This situ- services. ation traditionally reflects a similar issue within WHO, A related health system building block is medical prod- where the IHR programme is seen as a vertical one even ucts, vaccines and health technologies, which are central though it overlaps with other frameworks (eg, UHC, the to delivering emergency response under the IHR (2005). Sustainable Development Goals, Essential Public Health Plans for their bulk purchase, stockpiling and distribution Functions/Operations), with individual departments

Kluge H, et al. BMJ Glob Health 2018;3:e000656. doi:10.1136/bmjgh-2017-000656 5 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2017-000656 on 20 January 2018. Downloaded from and with other programmes responsible for delivering in and resilient health systems facilitates their emergency IHR-related areas (eg, the antimicrobial resistance and response capacity.30 Likewise, the GHRF Commission vaccine preventable diseases programmes). The impera- stresses the need to invest in national health systems to tive for improving internal coherence and joint working ensure a robust global health risk framework13 and civil has led to the creation of the new WHO Health Emergen- society too has pressed home this point.20 Additionally, cies Programme (WHE). Designed to build up WHO’s it should not be forgotten that public health crises also effective operational role in emergency preparedness carry economic, development and social consequences and during health crises, its establishment reflects a key that could be mitigated by better health system invest- recommendation of the Ebola Interim Assessment Panel ment upfront. The World Bank estimated the economic report.8 The new programme has one workforce, one impact of Ebola in Guinea, Liberia and Sierra Leone budget, one line of accountability, one set of processes/ through 2015 at US$2.2 billionix; the majority of which systems and one set of benchmarks, and maintains a were economic impacts that disproportionately affected standing interdepartmental task force at headquarters the poor. WHO itself has consistently stated that health and regional office levels. systems are at the heart of how countries respond to new Changes are also required in terms of more immediate disease threats, and sustained investment to keep them programmatic and day-to-day activities. One proposal is strong is required.16 Ultimately, investing in stronger and for the establishment of a WHO cross-cutting ‘task force’ more resilient health systems is investing in health secu- comprising staff from health systems, WHE (including rity and towards UHC.31 32 IHR) and other relevant programmes; for it is clear This is not a new message. And while its reiteration that there are a number of very practical questions in is important given recent public health emergencies, relation to embedding the IHR capacity requirements it needs to be more nuanced and mindful of different within health systemsviii. Such a WHO cross-cutting ‘task national settings. Simply calling on countries, such force’ and interdisciplinary group would provide guid- as those in West Africa, to invest more in order to ance where technical and operational details need to contribute to global health security through the IHR is be developed. The group is already looking to develop a not helpful as a way forward. Strategies and policies at matrix cross-referencing IHR (2005) capacities—specifi- regional and global level, to help lower-income coun- cally coordination, surveillance, response, preparedness tries strengthen their systems, will be crucial in respect and laboratory capabilities—with the six health system of future preparedness. In this regard, the need for a building blocks in order to draw out areas of synergy, global strategy for local investment in core capacity to promoting a systems approach, as well as for the JEE detect, report and respond rapidly to outbreaks is the areas of work. Moreover, there are key interlays with first recommendation of the Harvard-LSHTM Indepen- public health functions—all WHO regions have their dent Panel on the Global Response to Ebola,7 and others own frameworks29—which need to be developed. Such have further noted the need for a new funding source a group, through its inter-regional composition, would entirely.21 http://gh.bmj.com/ minimise silos and will introduce the IHR (2005) at all Equally clear is that governments need to see the IHR levels of WHO. as ‘theirs’ and as part of the national health system, such that investment can be sustained and activities institutionalised. As Ebola, and other global crises have Stronger and more resilient health systems to shown, health systems and global health security are only improve global health security as strong as their weakest link—this points to the most This paper has made an initial case for better embedding on September 27, 2021 by guest. Protected copyright. fragile and unprepared states, and our collective need the IHR (2005) into health systems, also highlighting to work together to strengthen not just their IHR (2005) WHO’s crucial role in supporting this. But what the capacities, but more fundamentally their health systems. discussion has also underlined—for the IHR (2005) and Insofar as the military provides an appropriate metaphor, for global health security more widely—is the importance it is important to plan, build and test our health systems’ of investing in health systems and activities to strengthen capacities and responsiveness during ‘peacetime’, them, both as an end of their own and so that they remaining attentive to the potential for ‘war’ through the become resilient to health emergencies and can deliver sudden emergence of health threats; when war erupts, health services in times when they are most needed. This it is too late to begin planning for it. Working towards a is also key in the pursuit of UHC. The message from the closer, embedded, relationship between the IHR (2005) US Institute of Medicine is that as health threats require and national health systems is an important step in this the deployment of the same skills and infrastructure direction, and WHO will need to play a leading role. that support routine healthcare, investing in strong Contributors HK provided strategic guidance. GP developed the concept and undertook the purposive literature review, and GP and HK drafted the manuscript. viii This proposal developed out of an inter-regional meeting hosted by the WHO European Regional Office in Copenhagen in April 2016 (http://www.euro.who.int/en/health-topics/Health-systems/pages/ news/news/2016/04/who-to-embed-international-health-regula- ix https://reliefweb.int/sites/reliefweb.int/files/resources/958040W- tions-in-health-systems-strengthening-process). P0OUO900e0April150Box385458B.pdf

6 Kluge H, et al. BMJ Glob Health 2018;3:e000656. doi:10.1136/bmjgh-2017-000656 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2017-000656 on 20 January 2018. Downloaded from

JMM, NE, GR, EK and MV reviewed the manuscript and provided expert input and infectious disease crises. 2016 https://www.nap.​ edu/​ catalog/​ ​ revision. GP is the author for correspondence. 21891/the-​ ​neglected-​dimension-​of-​global-​security-​a-​framework-​to-​ counter Disclaimer HK, NE, GR, EK, MV and GP are staff members of the World Health 14. Katz R, Fischer J. Global Health Governance. The Revised Organization. The author alone are responsible for the views expressed in this international health regulations: a framework for global pandemic publication and they do not necessarily represent the views, decisions or policies of response. 2010 http://www.​ghgj.or​ g/​Katz and Fischer_The Revised the World Health Organization. International Health ​Regulations.​htm 15. Chamberlin, Margaret, Adeyemi Okunogbe, Melinda Moore and Competing interests HK, NE, GR, EK, MV and GP work for WHO. JMM is a Mahshid Abir. Intra-action report — a dynamic tool for emergency consultant and advisor to the WHO Regional Office for Europe on public health. managers and policymakers: a proof of concept and illustrative Provenance and peer review Not commissioned; externally peer reviewed. application to the 2014–2015 ebola crisis. Santa Monica, CA: RAND Corporation, 2015. Data sharing statement No additional data are available. 16. World Health Organization. Everybody’s business: Strengthening health systems to improve health outcomes. WHO’s strategic Open Access This is an open access article distributed under the terms of the framework for action. 2007 http://www.​who.​int/​healthsystems/​ Creative Commons Attribution-NonCommercial IGO License (CC BY-NC 3.0 IGO), strategy/​everybodys_​business.​pdf. which permits use, distribution,and reproduction for non-commercial purposes 17. Shoman H, Karafillakis E, Rawaf S. The link between the estW in any medium, provided the original work is properly cited. 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